Resected squamous lung cancer and now adrenals suspicious

Portal Forums Lung/Thoracic Cancer NSCLC General NSCLC Resected squamous lung cancer and now adrenals suspicious

This topic contains 36 replies, has 5 voices, and was last updated by catdander forum moderator catdander forum moderator 3 weeks, 5 days ago.

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July 11, 2016 at 7:14 pm  #1274644    
JimC Forum Moderator
JimC Forum Moderator

Hi volume,

I’m sorry to hear of your father’s suspected pneumonia. In terms of the duration of chemotherapy, many oncologists prefer to stop after 4 cycles, since the great majority of benefit occurs during those cycles, and additional cycles tend to add more toxicity, not worth it for any small additional benefit they may provide. When a regimen is well-tolerated and continued benefit appears after 4 cycles, some oncologists may continue.

Docetaxel is a drug that has shown activity in squamous cell lung cancers, but it can be quite challenging in terms of side effects. Dr. West wrote a post on the subject of using Tarceva for squamous, showing a modest, but real, benefit. There are some pretty encouraging results from immunotherapies, so it might be worth trying to get an approval for it.

Generally radiotherapy is not used in the metastatic lung cancer setting unless it’s to alleviate or prevent serious pain or problems such as bone fractures, but exceptions are made when there are only one or two distant metastases. That might be a topic to discuss with your father’s medical team.

JimC
Forum moderator


Jul 2008 Wife Liz (51/never smoker) Dx Stage IV NSCLC EGFR exon 19
4 cycles Carbo/alimta, 65% shrinkage
Tarceva maintenance
Mar 2010 progression, added Alimta, stable
Sep 2010 multiple brain mets, WBR
Oct 2010 large pericardial effusion, tamponade
Jan 2011 progression, start abraxane
Jun 2011-New liver, brain mets, add Tarceva
Oct 2011-Dx Leptomeningeal carcinomatosis; pulsed Tarceva
At rest Nov 4 2011
Since then: http://cancergrace.org/blog/jim-and-lisa

August 17, 2016 at 8:14 am  #1288335    

volume

Hey, everyone, I am back to report on my dad’s case.
First of all, my dad’s pneumonia was caught just on time and he spent only 3 days in hospital.
The other thing is he finished all 6 cycles of CarboTaxol, and I am amazed by how brave he is. It is truly inspiring to see him fight this disease and not give up in the face of cancer. He quit smoking and follows the diet prescribed by doctors to the letter! Note to anyone starting this battle, be brave, listen to your doctor’s and it is going to be OK! :)

As a whole, other than losing his hair, the occasional nausea and joint paint, chemo hasn’t hit him very bad.
Unfortunately, his doctors gave him an ECOG 3 performance status, which I have seen as a hurdle in some clinical trials, should he elect to do any. Does performance status get upgraded or does it only go up in numbers? I don’t think he is at 3, he cooks and walks his morning cafe/newspaper/shopping routine every day and doesn’t nap more than 2 hours a day. Is performance status a factor in what treatments he can or cannot do?

I will soon be speaking to his doctors, as he is getting a PET scan in September, but I want to be prepared for that meeting since oncology here is more in the hands of patients than doctors.. you need to push your way to treatment and the more you know beforehand the better since doctors are always in a hurry.

And also, once again, thank you! You have all helped me and my dad more than you can imagine!

August 17, 2016 at 2:50 pm  #1288337    
catdander forum moderator
catdander forum moderator

volume,

Thank you for your kind words. Jim and I have benefited in the same way.

The performance status of a person isn’t a static diagnosis but follows a person’s abilitity levels due to changing health. Doctors and their teams who conduct clinical trials will evaluate appropriate candidates for a specific trial. To help understand your dad’s oncologist’s thinking it may be of help to take a copy of the ECOG performance status list, like the one below to reference during the meeting. Also having personal knowledge of how your dad performs on a daily basis can help his onc make the best decisions for treatment.

ECOG Performance Status
Developed by the Eastern Cooperative Oncology Group, Robert L. Comis, MD, Group Chair.*

GRADE ECOG PERFORMANCE STATUS
0 Fully active, able to carry on all pre-disease performance without restriction
1 Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light house work, office work
2 Ambulatory and capable of all selfcare but unable to carry out any work activities; up and about more than 50% of waking hours
3 Capable of only limited selfcare; confined to bed or chair more than 50% of waking hours
4 Completely disabled; cannot carry on any selfcare; totally confined to bed or chair
5 Dead
*Oken M, Creech R, Tormey D, et al. Toxicity and response criteria of the Eastern Cooperative Oncology Group. Am J Clin Oncol. 1982;5:649-655. http://ecog-acrin.org/resources/ecog-performance-status

You’re right in knowing you need to be prepared for the appointment. Bring a list of questions and take notes. Know as much as possible so you can be ready, we have lots of info. It’s impossible for an oncologist to explain all their is to know so letting the onc know where your knowledge base is will allow the doctor to have an intelligent conversation without having to give lessons on cancer care. Usually oncologists welcome this type of dialogue.

All best,
Janine

September 10, 2016 at 12:17 am  #1288566    

volume

Hello, everyone. I am back with an update. My father’s PET/CT results just came in. Unfortunately the news is not all too good. His right adrenal gland is indeed metastatic 55/48 cm with SUVmax 9.34. The good news is.. if there can be any in this situation… that there are no other lesions.

Does this SUV number indicate an aggressive and active cancer? Also given such a result after 6 cycles of chemo, is it fair to say that my dad isn’t really responding?

I was also wondering what symptoms might we expect with such metastasis? Just pain or some hormonal dysfunction?

I am editing this, as I managed to get a hold of the head oncologist of my father’s chemotherapy team. Her opinion was: no more chemo, the side-effects would be too much but we should act now before any symptoms appear. Her recommendation is either surgery or radiotherapy.
My dad doesn’t want to do the surgery and the oncologist also mentioned radiotherapy is a better option but cyberknife is not really an option due to the lesion size. I’ve already booked 2 consults for next week with radiotherapy specialists. Is radiotherapy effective in these cases? I am aware a cure is not on the table, but at least stable disease?

  • This reply was modified 1 year, 3 months ago by  volume.
  • This reply was modified 1 year, 3 months ago by  volume.
September 10, 2016 at 6:55 am  #1288572    

cards7up

I would think it would be mm not cm since the adrenal gland isn’t even that large. “The adrenal gland weighs on average 4-6 g and measures 4-6 cm long and 2-3 cm wide.” If it was 55 cm, then it would be 21 inches. And 4-6 cm is @ 2 inches.IMHO, I’d want further testing, a 24 hour blood and urine test measures the amount of adrenal hormones. Typically, the higher the SUV then the more likely it’s cancerous, but not always. The rad onc is the one who can tell if SBRT can be used, so I’d wait to hear their opinion. What about opdivo?
Take care, Judy


Stage IIIA adeno, dx 7/2010. SRS then chemo carbo/alimta 4x. NED as of 10/2011.
Local recurrence, surgery to remove LRL 8/29/13. 5.2cm involved pleura. Chemo carbo/alimta x3. NED

September 10, 2016 at 7:18 am  #1288573    
JimC Forum Moderator
JimC Forum Moderator

Hi volume,

I’m sorry to hear of the appearance of the adrenal metastasis, but I don’t know that you can say that is means that your father’s chemo is not working at all. If the scan showed shrinkage or stability in other areas, then he may have had a “mixed response” in which some cancer cells respond and others do not. As stated in your earlier thread, it may also be true that the adrenal masses simply aren’t cancer, which would explain their lack of response to chemo. But his own doctors have all of his information available, so their opinion is the best-informed one. I do agree that it’s valuable to get more than one opinion.

As far as symptoms of adrenal metastases, the American Association of Endocrine Surgeons state:

“Sometimes a patient will have symptoms related to the growth of their adrenal metastasis, for example abdominal or back discomfort. Rarely, if both adrenal glands are involved with metastases, a patient may develop symptoms related to insufficient production of steroid hormones by the involved adrenal glands (adrenal insufficiency or Addisonian state). Adrenal insufficiency is characterized by weakness, low blood pressure, low blood sugar, low blood sodium and high potassium levels, and darkening of the skin.”
http://endocrinediseases.org/adrenal/metastases_symptoms.shtml

Radiotherapy can effectively treat such metastases, and there is a recent trend in the past few years to give local treatment to such “oligometastases” (where the cancer has spread to just one or two locations outside the lung) with curative intent, in the hope that this is the only distant location where cancer cells are present.

JimC
Forum moderator


Jul 2008 Wife Liz (51/never smoker) Dx Stage IV NSCLC EGFR exon 19
4 cycles Carbo/alimta, 65% shrinkage
Tarceva maintenance
Mar 2010 progression, added Alimta, stable
Sep 2010 multiple brain mets, WBR
Oct 2010 large pericardial effusion, tamponade
Jan 2011 progression, start abraxane
Jun 2011-New liver, brain mets, add Tarceva
Oct 2011-Dx Leptomeningeal carcinomatosis; pulsed Tarceva
At rest Nov 4 2011
Since then: http://cancergrace.org/blog/jim-and-lisa

September 10, 2016 at 8:25 am  #1288575    

volume

Thank you for your quick responses. Yes, my bad, its 55/48 mm. Which is more or less stable in size since the CT following the 4th carbotaxol cycle.

So far my dad has not had any symptoms, luckily, but it may indeed be wise to test hormones as well, it would do no harm I suppose.

As far as Opdivo is concerned, here, it is only available through an early access program at one hospital. We have a consult for next week there and I will ask about it. Otherwise the national health fund might finance some other immunotherapy drugs, but our local center is certainly not using these. Still, it won’t hurt to ask next week about that option as well. Unfortunately, we can’t afford to buy the Opdivo ourselves. For not immunotherapy looks like a long shot. State funding has its benefits, but as you can see, also its disadvantages.. slow adoption of new drugs, budget limitations, etc. Luckily, so far the treatment has cost us nothing, save for a few consults.

All that said, radiation therapy seems to be the easies route, and hopefully it will stop the lesion in its tracks. I just hope the side effects are not too severe, since the right adrenal seems to be pretty close to some important organs.

Once again, thank you, and have a great weekend!

September 10, 2016 at 12:30 pm  #1288582    
catdander forum moderator
catdander forum moderator

There are several immunotherapy drugs being tested. Those that have completed studies and are found to be effective are Nivolumab (Opdivo), pembrolizumab (Keytruda), and Tecentriq (atezolizumab). They have all shown to have efficacy in people with nsclc especially in those with at least a 50% expression of pd-l1 (mostly found in people with a nsclc with squamous histology).

So there’s no one immunotherapy drug that is clearly better than another. If one is available then that would be the obvious choice.

Best of luck,
Janine

October 5, 2016 at 10:12 am  #1288866    

volume

Hello again,

I wanted to drop by to mark the 1 year mark since my dad’s cancer was diagnosed. At the moment my father is getting SBRT to his right adrenal. Today was the 3rd visit out of a total of 6. Hopefully, that will buy him at least another year (or more!). If that fails, I’ll just start asking around for immunotherapy. Best wishes to all of you!

October 6, 2016 at 4:34 am  #1288869    
JimC Forum Moderator
JimC Forum Moderator

Hi volume,

Thank you for the update and congratulations to you and your father on reaching this milestone. I hope that the radiation is successful, and that your next update contains nothing but good news!

JimC
Forum moderator


Jul 2008 Wife Liz (51/never smoker) Dx Stage IV NSCLC EGFR exon 19
4 cycles Carbo/alimta, 65% shrinkage
Tarceva maintenance
Mar 2010 progression, added Alimta, stable
Sep 2010 multiple brain mets, WBR
Oct 2010 large pericardial effusion, tamponade
Jan 2011 progression, start abraxane
Jun 2011-New liver, brain mets, add Tarceva
Oct 2011-Dx Leptomeningeal carcinomatosis; pulsed Tarceva
At rest Nov 4 2011
Since then: http://cancergrace.org/blog/jim-and-lisa

October 10, 2016 at 10:46 pm  #1288894    

volume

I’m back here sooner than I anticipated, since the radiation oncologists have asked my father to think about having his other adrenal gland treated with SBRT as well, even though the PET/CT did not show any metabolic activity. This seems a bit odd to me, but they said it would be wiser to do it now, when its 4.4 cm x 2.8 cm, rather than later, when higher doses would have to be used. Is such a “preemptive” treatment usual in this setting? Does metastatic disease tend to hop to the other adrenal?
It’s the first time I’ve heard of such an option, even though I’ve read a lot of sources on the subject.
They told us to think about it for a month, since that is the earliest they can start.
I am worried that having more radiation to the abdomen might cause toxicities. So far my dad has had no side effects after 6 x 7 Gy to the right adrenal, but who knows what more radiation would do.

October 11, 2016 at 9:19 am  #1288896    
catdander forum moderator
catdander forum moderator

Hi volume,

There are extenuating circumstances for everything cancer but I’ll ask an oncologist to weigh in here.

All best,
Janine

January 20, 2017 at 1:14 am  #1289864    

volume

Hello again! I’ve come back with an update on my father, and it’s good news. The SBRT to his adrenal resulted in a “complete metabolic and partial morphologic response”, i.e. it went from 9.3 to 2.6 SUVmax and from 5.8 to 4.3 cm in the biggest dimension. No other lesions detectable anywhere else, so woohoo! We will be celebrating his 73 birthday next week with big smiles on our faces.

I hope this small victory 1 year and 2 months after his diagnosis will bring courage and hope to all other patients and caregivers who read this.

January 21, 2017 at 5:59 am  #1289866    

cards7up

Congrats to your Dad and have a very Happy Birthday!
Take care, Judy :-P


Stage IIIA adeno, dx 7/2010. SRS then chemo carbo/alimta 4x. NED as of 10/2011.
Local recurrence, surgery to remove LRL 8/29/13. 5.2cm involved pleura. Chemo carbo/alimta x3. NED

January 21, 2017 at 7:50 am  #1289867    
JimC Forum Moderator
JimC Forum Moderator

That’s terrific news, and thanks for sharing it with us. As you say, success stories help all who are battling cancer.

I hope your father and your whole family enjoy his birthday next week. Happy Birthday from all of us here at GRACE!

JimC
Forum moderator


Jul 2008 Wife Liz (51/never smoker) Dx Stage IV NSCLC EGFR exon 19
4 cycles Carbo/alimta, 65% shrinkage
Tarceva maintenance
Mar 2010 progression, added Alimta, stable
Sep 2010 multiple brain mets, WBR
Oct 2010 large pericardial effusion, tamponade
Jan 2011 progression, start abraxane
Jun 2011-New liver, brain mets, add Tarceva
Oct 2011-Dx Leptomeningeal carcinomatosis; pulsed Tarceva
At rest Nov 4 2011
Since then: http://cancergrace.org/blog/jim-and-lisa

November 21, 2017 at 1:58 pm  #1293543    

volume

Hello to everyone. I hope you are all doing well. Once again I seek some sound advice from this forum, as it has been quite helpful in the past.

It has already been 2 years since my dad’s diagnosis and operation. Latest CT scans show he is still NED. Bloodwork is normal, lung function is normal (for a lobectomy patient at least). He did have a bronchoscopy because he has a productive cough but the biopsy showed no malignancy.

As in a few days I will be meeting with his oncologist at her request to discuss whether my father should go from a 3 month to a 6 month control with CTs. Is this the normal way to go 2 years following diagnosis? Also, wouldn’t a PET scan be advisable at least once a year? I am really not sure if there is a protocol or are such decisions up to the medical team of the patient?

November 21, 2017 at 4:25 pm  #1293544    
catdander forum moderator
catdander forum moderator

Dr. West has this to say about follow up post curitive treatment for lung cancer.

“Physical examination by the physician and CT scan of the chest every 4-6 months for the first 2 years and then once a year.

“Recurrence of lung cancer tends to occur in the first 2-3 years after completion of treatment though in some patients the recurrence may occur later. Therefore in the first 2 years the scans are done more frequently. The reason only CT scans of the chest are done is that the common areas of recurrence are both lungs, adrenal glands (that are in the upper abdomen and included in a CT scan of the chest) and liver. The purpose of the CT scans of the chest is also to detect if the patient has developed a second lung cancer, separate from the first lung cancer. Any lung cancer patient has a risk of developing a second lung cancer though the risk is low. Both organizations do not specify for how many years should the CT scans be done though many doctors do scans for 5 years. A lot of patients ask for a PET scan. But there is no known value in doing a PET scan for routine follow up after completing treatment for early stage lung cancer.”

http://cancergrace.org/lung/2008/08/10/fu-after-resection/

Since this post a study showed yearly scans are beneficial for those most likely to develop lung cancer and a previous lung cancer fits in that category. So once a year from past the 2 year mark. But I’ve always counted that from the last treatment.

Congrats to your mom, you and your family. I know how thankful you all most be.

Janine

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